| NPI | 1689641201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 2527) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WI 148638) |
| Enumeration Date | 2006-03-02 |
| Last Update Date | 2016-05-23 |